When to Say, “You’re Fired!”

Dear Director,
I’m a medical director and have one doc who I’m under pressure by administration to fire. Although he’s a good clinician who saves lives, at least once a week he gets complaints from patients, nurses, non ED attendings, etc…What can I do? It’s either going to be him or me, but I don’t really want to see him go.
Signed,
Riding out the Storm

We’ve all worked with providers whose presence alone can change the mood and tone of the ED. Whether it’s the whirling dervish who adds a chaos factor, the non-stop whiner or a doc who always causes patient complaints which then ties up the charge nurse, it’s frustrating to feel like a colleague is pulling the team down. Your situation is complicated by the fact that your troublemaker has caused enough problems that your hand is being forced and failure to follow through could cost you your leadership position. Also, it sounds like your doc may be so good that they’re actually the person you would want caring for you if you were an ED patient.

The House Rules
The first person to point the finger at in this case is yourself. If the C-Suite is telling you to fire someone, then you’ve been remiss in your responsibilities as a leader and missed the opportunity to reign in this provider. If it’s reached the point of an executive order, the horse may be out of the barn and you’ll have no option. Remember, it’s the CEO’s house and we all live under their roof and must play by their rules. However, if allowed to discuss options, focus on the providers positives and it’s possible that the CEO will accept a remediation plan.

The Game Plan
As the medical leader, it’s your job to lead, mentor, challenge, coach and develop all of your staff, preferably before one hits a breaking point. This means attacking their weaknesses, which may include personality disorders. If the CEO is allowing a remediation plan, you must be very clear with the provider about the situation. This starts with a scheduled meeting outside of routine clinical time so the provider can recognize the gravity of the situation and focus their attention appropriately. If you believe this doc is fantastic, and he thinks of himself as a great doc, you both need to accept the fact that fantastic docs don’t get many complaints and certainly don’t cause trouble. You’re either great in all aspects of your job or you’re not great—you don’t get it both ways. Then outline the problem and give examples of inappropriate behavior (i.e. your overreactions to someone deviating from your plan and then screaming at a nurse). You may then try some coaching and counseling of more appropriate behaviors. Even though I personally roll my eyes every time I have to role-play, you might find it useful to walk through situations with this provider. If you’ve tried this unsuccessfully or are uncomfortable doing it, consider getting recommendations from your group’s or hospital’s human resources department or medical staff office about different types of counseling available to professionals. Your provider should know that you’re motivated to help them save their job, but ultimately it will be their responsibility.

The process that you develop with the provider should be mapped out, written down, and should have a time frame attached. This should be agreed upon and signed by both you and Dr. Trouble. This helps you explain the remediation process to your administration and keeps your whirling dervish on track. It is not unheard of to mandate that an employee undergo counseling to address an issue (frequently seen with anger management in physicians or substance abuse) in order to keep a job. As you go down this road with your physician, it’s also critical to outline the consequences of inaction or failure to improve, which in this case is loss of his job but also potentially loss of the entire group’s contract and thus all of his colleagues jobs.

An obvious alternative philosophy is that sometimes you need to fire an employee; everyone is replaceable. If the leader of the free world can change every four to eight years, I’m pretty sure your department can absorb the loss of a physician. Let’s be clear: it’s in everyone’s best interest to have the doc improve upon their weakness and become an outstanding member of your department. Recruitment and training take time and money. More importantly, as painful as it is to personally fire someone, the person being fired has it much worse. Removing someone from your staff can impact that doc’s life for years. It’s a true shame to see professionals not functioning at their potential and simply removing them from your staff doesn’t help them down the line. But the bottom line remains: everyone is replaceable.

Weathering the Storm
The beauty of your problem is that there will be resolution and you will ultimately get to that calm after the storm. I’ve seen plenty of docs undergo this process and reach a maturation level that makes them an outstanding team member and reduces the number of complaints dramatically. I’ve seen other very popular docs removed from a staff and, while sometimes you miss their positive features, the department hums along a little bit nicer. There will come a time that you can’t quite put your finger on, but you’re pretty sure you’ve weathered a storm and things are looking brighter.

Comments

Hopefully this troublesome doctor has been made aware of all of these patient complaints and the staff complaints have been tracked in writing. If he has been insulated from the complaints, and if the staff complaints really amount to complaining about him when he is not around it is going to be difficult to easily fire him. The documentation needs to be excellent or your partnership is going to end up paying him out instead of going through a long court case. All to often documentation in these cases is horrible and it puts the fired person in an easy position to sue.